Kingsway Home Health Services, Inc.

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the review of the Error Summary report and staff interview, it was determined in 33 of 74 assessments submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 03/01/24 to 03/26/25, was reviewed on 04/14/25 at 10:30 AM. The report included error # -3330 (Record Submitted late: The Submission date is more than 30 days after the date assessment was completed on this record), for 34 of 74 late submissions, 44.59 % of the OASIS reports submitted, were more than 30 days after the assessment was completed. 2. During an interview with the Director of Nursing on 04/15/25 at 4:00 PM, it was confirmed that the error occurred.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review, home visit interview and staff interviews, it was determined for 3 of 7 (Pts. #5, #6 and #3) clinical records reviewed, the Agency failed to ensure care was provided as ordered by the Physician as indicated in the POC. 3. Pt. #3 was admitted to the home health services on 04/04/25 with the diagnoses of Muscle Weakness and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 04/15/25. The clinical record contained a POC dated 04/04/25, that required the “sharps safety”. On 04/15/25 at 11:30 AM, a home visit was conducted with the PT. During the home visit interview, the patient’s daughter stated they were not provided with the sharp container and was disposing sharps into their garbage container. 4. The above findings were confirmed, during the interview with the Director of Nursing, on 04/15/25 between 2:30 PM and 3:30 PM. Findings include: 1. Pt. #5 was admitted to home health services on 08/31/24 with the diagnosis of Other Polyosteoarthritis. The clinical record was reviewed on 04/15/25, and included the POC effective 02/27/25 which required, “Orders for Discipline and Treatment, Nursing…SN to assess Pt.’s O2 sat level every SN visit and report saturation less than 90% to MD.” The SN notes for the following dates 03/17/25, 03/31/25 and 04/07/25, lacked documentation of reading for O2 saturation. 2. Pt. #7 was admitted to home health services on 08/31/24 with the diagnosis of but not limited to Pain in the Right Knee and Unspecified Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 04/15/25, and included the POC for the certification period of 12/14/24 to 02/01/25 which required, “Orders for Discipline and Treatment, Nursing…SN to weigh patient Q visit and to keep a log of daily weights and report and increase of 2 lbs./day or 5 lbs./week to MD.” The SN for the following dates 12/11/24 and 12/18/24, lacked documentation of the Pt.’s weight.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, home visit observation and staff interview, it was determined that for 3 of 7 (Pts. #1, #2 and #3) clinical records reviewed, the Agency failed to ensure, at time of admission, a copy of the Agency’s transfer and discharge policy was provided to Pts. and their families. Findings include: 1. The Agency Pt. admission folder provided by the Agency was reviewed on 04/14/25 and 04/16/25. The folder lacked a copy of the Agency’s transfer and discharge policy. 2. The following home visits were conducted from 04/14/25 at 3:30 PM to 04/15/25 at 12:30 PM: Pt. #1. SOC 03/17/25. Pt. #2. SOC 11/20/24. Pt. #3. SOC 03/28/25. During the home visits, the Pt. admission folders were observed and lacked a copy of the Agency’s transfer and discharge policy. 3. During an interview with the Director of Nursing on 04/16/25 at 11:30 AM, the Director of Nursing indicated the same admission folder is given to all Patients and, confirmed the admission folder did not contain a copy of the Agency’s transfer and discharge policy.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, home visit observation, and staff interview, it was determined that for 3 of 7 (Pts. #1, #2 and #3) clinical records reviewed, the Agency failed to provide information regarding the Administrator and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 04/16/25. The folder lacked documentation identifying the Agency Administrator’s name, their address and phone number to file a complaint and/or grievance. 2. The following home visits were conducted from 04/14/25 at 3:30 PM to 04/15/25 at 12:30 PM: Pt. #1. SOC 03/17/25. Pt. #2. SOC 11/20/24. Pt. #3. SOC 03/28/25. During the home visits, the Pt. admission folders were observed and lacked the Agency’s Administrator, their address and phone number to file a complaint and/or grievance. 3. During an interview with the Director of Nursing on 04/16/25 at 11:30 AM, it was confirmed this was the admission folder used for all admissions and that the folder lacked contact information for the Administrator.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on clinical record reviews, policy review and staff interviews, it was determined for 2 of 7 (Pts. #5 and #4) clinical records reviewed, the Agency failed to ensure PsOC included all the requirements. 2. Pt. #4 was admitted to the home health services on 08/09/24 with the diagnosis of Type 2 Diabetes “w unsp diabetic rtnop w/o macular edema”. The clinical record was reviewed on 04/15/25. The clinical record contained a POC dated 04/06/25 that required the SN to assess the patient. The POC lacked the frequency for the SN services, provided by the Agency. 3. The above findings were confirmed, during the interview with the Director of Nursing, on 04/15/25 between 2:30 PM and 3:30 PM. Findings include: 1. Pt. #5 was admitted for home health services on 08/31/24 with the diagnoses of Other Polyosteoarthritis. The clinical record was reviewed on 04/15/25. The Plan of Care effective 02/27/25 lacked documentation of vital signs parameters.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on review of clinical records and staff interview, it was determined that for 2 of 2 (Pts. #6 and #7) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the Discharge Summary within 5 days after discharge. Findings include: 1. Pt. #6 was admitted to Home Health Services on 07/19/24 with the diagnosis of Mild Cognitive Impairment. The record contained a Discharge comprehensive assessment dated 09/10/24, indicating that Pt. #6 was discharged from the Agency. The record lacked documentation that a copy of the Pt.’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 12/04/24 with the diagnosis of Pain in Right Knee. The record contained a Discharge comprehensive assessment dated 01/15/25, indicating that Pt. #7 was discharged from the Agency. The record lacked documentation that a copy of the Pt.’s discharge summary was sent to the Physician. 3. During an interview with the Director of Nursing on 04/16/25 at 11:30 AM, the above findings were confirmed.”